Transcript Is this a refractory ascites?

Approach - Management
of ascites
in cirrhotic patients
Dr . Khaled sheha
Causes of ascites
Causative disorders
Percentage
Cirrhosis
85%
PHT-related disorder
8%
Cardiac disease
3%
Peritoneal carcinomatosis
2%
Miscellaneous non-PHT disorders
2%
Diagnosis of ascites
*
• Ascites can be graded as
Grade 1 (mild)
Detectable only by US
Grade 2 (moderate)
Moderate abdominal distension
Grade 3 (large)
Marked abdominal distension
* Moore KP et al. Hepatology 2003 ; 38 : 258 – 66.
Ascites grade 1
Detectable only by US
Pathogenesis of ascites in cirrhosis
PHT
 Nitric oxide
Vasodilatation
Renal Na retention
 Sympathetic activity
 RAA system
Overfill of
intravascular volume
Ascites formation
Indications for diagnostic paracentesis
• Patients with new-onset ascites
• Cirrhotic patients with ascites at admission
• Cirrhotic patients with ascites & symptoms or signs
of infection: fever, leukocytosis, abdominal pain
• Cirrhotic patients with ascites & clinical condition
deteriorating during hospitalization: renal function
impairment, hepatic encephalopathy, GI bleeding
Needle-entry sites
Superior & inferior epigastric arteries run just lateral to the
umbilicus towards mid-inguinal point & should be avoided
.
The Z-tract technique
Green (21 G) or blue (23 G) needle
Diagnostic purpose: 10- 20 ml of fluid ascites
Cytologic study: 50 ml of fluid ascites
Thomsen TW et al. N Engl J Med 2006 ; 355 : e21.
The angular insertion technique
Green (21 G) or blue (23 G) needle
Diagnostic purpose: 10- 20 ml of fluid ascites
Cytologic study: 50 ml of fluid ascites
.
What are the contraindications &
complications of paracentesis?
MA
Complications of paracentesis
• Abdominal hematomas
Up to 1 % of patients
Rarely serious or life threatening
• Hemoperitoneum or bowel perforation
Rare (< 1/1000 procedures)
Serious complications
Guidelines on management of ascites in cirrhosis.
Gut 2006 ; 55 ; 1 – 12 .
Contraindications to paracentesis
• Clinically evident fibrinolysis or DIC
Preclude paracentesis
• Abnormal coagulation profile
Paracentesis not contraindicated
Majority of pts have prolonged PT & thrombocytopenia
No data to support the use of FFP before paracentesis
AASLD practice guidelines
Runyon BA. Hepatology 2004; 39: 841 – 856.
Ascitic Fluid Laboratory Data
Routine
Optional
Unusual
Unhelpful
Cell count *
Culture
TB smear & culture
pH
Albumin
Glucose
Cytology
Lactate
Total protein
LDH
TG
Cholesterol
Amylase
Bilirubin
Fibronectin
Gram’s stain
* Automated counting can replace manual cell count
.
Serum Ascites Albumin Gradient (SAAG)
Albumin Serum – Albumin Ascites
(g/dL)
(g/dL)
in the same day
Differential diagnosis according to SAAG
High Gradient
≥ 1.1 g/dL
Low Gradient
< 1.1 g/dL
Differential diagnosis of ascites
according to SAAG
High Gradient
≥1.1 g/dL (11g/L)
Low Gradient
<1.1 g/dL (11g/L)
Cirrhosis
Peritoneal carcinomatosis
Liver metastases
Tuberculous peritonitis
Cardiac ascites
Pancreatic ascites
Portal-vein thrombosis
Biliary ascites
Budd–Chiari syndrome
Nephrotic syndrome
Hypothyroid
Serositis
.
What is the treatment?
Tapping ascitic fluid (1672)
German National Museum, Nürnberg, Germany
What do you prescribe to this patient?
What are the side effects of these drugs?
How do you follow-up the patient?
ND
Recommendation
Low sodium diet
Dietary salt should be restricted to a no-added
salt diet of 90 mmol salt/day (5.2 g salt/day) by
adopting a no-added salt diet & avoidance of
pre-prepared foodstuffs
ND
Diuretics treatment in cirrhotic ascites
Oral route – Single morning dose
Progressive Schedule
Combined Schedule
SP *
100  200  300  400 mg/d
SP 100 mg/d
+ FUR 40 mg/d
Progressive increase every 3-5 days
SP 400 mg/d + FUR**
40  80  120  160 mg/d
*SP
**FUR
SP 200  300  400 mg/d
+ FUR 80  120  160 mg/d
Spironolactone
Furosemide
Follow-up of patients on diuretics – 1
• Weight loss
Massive edema
Resolved edema
No limit to daily weight loss
 0.5 kg / day
• Weight loss less than desired
24-hour urine sodium
> 78 mmol/24h & no weight loss: patient not compliant
< 78 mmol/24h & no weight loss: increased diuretics
“spot” urine NA/K>1= 24-hour urine Na>78 mmol/24h
Follow-up of patients on diuretics – 2
• Body weight
• Blood pressure
• Pulse
• Electrolytes
• Urea
• Creatinine
Every 2 – 4 weeks
Every few months thereafter
Side effects of diuretics
• Spironolactone
Men
 libido, impotence, gynecomastia
Women
Menstrual irregularity
• Hydro-electrolytes disturbances
Hypovolemia: hypotension – renal insufficiency
Hyponatremia
Hypo or hyperkalemia
Hepatic encephalopathy
Water restriction
• Not necessary in most cirrhotic patients with ascites
• Cirrhotic patients have symptoms from hyponatremia
if Na < 110 mmol/L or if very rapid decline in Na
• Water restriction indicated in patients who are clinically
euvolaemic withs severe hyponatraemia & not taking
diuretics with normal creatinine
• Avoid increasing serum sodium > 12 mmol/l per day
ND
Bed rest in cirrhotic ascites
• Upright posture associated with activation of RAA
system, reduction in GFR & sodium excretion, &
decreased response to diuretics
• Bed rest  muscle atrophy & other complications
• No clinical studies to demonstrate efficacy of bed rest
Recommendation
Bed rest
Bed rest is NOT necessary for the
treatment of cirrhotic ascites
How do you treat the tense ascites
in this patient?
OH
Is this a refractory ascites?
How do you treat refractory ascites?
RA
Refractory ascites ( 10 %)
• Diuretic resistant ascites
Unresponsive to LSD (< 88 mmol/day)
& High-dose diuretics
SP 400 mg & FUR 160 mg/d
for at least
1 week
• Diuretic intractable ascites
Diuretic induced complications Encephalopathy
Creatinine > 2.0 g/dL
Na < 125 mmol/L
K > 6 or < 3 mmol/L
International ascites club
Arroyo V et al. Hepatology 1996 ; 23 : 164 – 76.
Recommendations
Treatment of refractory ascites
• Therapeutic paracentesis is the first line treatment:
< 5 L:
Colloid - No need for albumin
> 5 L:
Albumin after paracentesis (8g/l)
• TIPS should be considered in refractory ascites
• LT referral should be considered in refractory ascites
• Peritoneovenous shunt should be considered in patients
who are not candidates for paracentesis, TIPS, or LT
ND
Refractory Ascites
LT evaluation
LVP + Albumin
1st Step
Na restricted diet (90 mEq/d)
Fluid restriction if Na < 130 mEq/L
Repeated LVP + albumin
Maintenance
Treatment
Preserved liver function?
Loculated ascites?
Paracentesis more frequent than 2-3 /month?
No
Yes
Continue LVP + Albumin
Consider TIPS
Clin Gastroenterol Hepatol 2005 ; 3 : 1187 – 1191.
Treatment of refractory ascites
• Serial therapeutic paracentesis
• TIPS
• Liver transplantation
• Peritoneovenous shunt: LeVeen – Denver
TIPS for refractory ascites
I
s
practice guidelines
Runyon BA. Hepatology 2004; 39: 841 – 856.
Albumin in cirrhotic ascites
• Large paracentesis > 5 L
8 g albumin/liter of ascites removed
(100 ml of 20% albumin / 3 L ascites)
• SBP with renal impairement
First six hours 1.5 g albumin / kg bw
Day 3
1g albumin / kg bw
• HRS-I
First day
1 g / kg bw (maximum 100 g)
Following days 20 – 40 g / day
Prognosis of ascites in cirrhotic patients
• Ascites
50 % survival at 2 years
• Refractory ascites
50% survival at 6 months
25% survival at 1 year
• SBP
30 - 50% survival at 1 year
• HRS-2
40% survival at 6 months
• HRS-1
< 5% survival at 6 months
Referral to liver transplantation unit